How to Set Up Validation Rules in EZClaim

How to Set Up Validation Rules in EZClaim

EZClaim medical billing software has many features built into the program to help you submit clean claims for quick payment and some that can be customized to fit your specific needs. This post will look at the ability to create customized validation rules.

Your EZClaim program already includes standard validation rules. To access these rules and create your own, press CTRL-ALT-V.  This will open the Rule Library.

Here you will find four different types of rules to work with, rules related to:

  • Sending claims
  • Saving a patient
  • Saving a payer library entry
  • Saving a physician library entry

 

Now, click on the rule type you would like to work with and click Edit Rules. A list of rules that are already in the program will appear, along with the option at the top to “Add new validation rule“.

To get started, you will fill in the fields on the bottom left side of the screen:

Name: Name the rule anything you would like
Field: This is the field in Premier that you want to validate
Message:  This is the message that will show when the error is encountered (consider using casual wording or extra punctuation so it is easily identified as a custom rule rather than a default rule)
Severity: Do you want the program to simply warn you that there may be an error or stop you from completing the task?

 

Next, you will build the logic for the validation of the field you have named above.  In the example below, the rule has been created to warn users if ALL the following statements are true:

  • Authorization Number is blank
  • Procedure Code is 90876
  • Payer is Blue Cross

 

Before you begin working with your validation rules it is extremely important to keep the following in mind:

  • Rules are created to check for bad or missing data, not to confirm good data.
  • Rules in the Sending Claims area may prevent batches from being created.
  • If you wish to bypass a built-in validation rule you may disable it, if you want to customize it you can Copy the rule, update, and disable the original rule.
  • Rules are the sole responsibility of the practice, EZClaim cannot troubleshoot custom validation rules.

 

As you can see, custom rules allow you to be very specific and can include multiple data points. Learning to use validation rules can be tricky and may take a few tries to get the rule built correctly. However, once you have the rule in place you can avoid payment delays and needing to resubmit claims.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s websiteemail them, or call them today at 877.650.0904.

Why Did My Medical Billing Claim Get Denied?

Why Did My Medical Billing Claim Get Denied?

If a medical billing program has “scrubbing,” why did my medical billing claim still get denied? It is a common question that we are going to answer today.

First, let’s get a better understanding of the words we are talking about.  In the medical billing world, validation and scrubbing tend to be used interchangeably.  While they are similar – they are not actually the same. Understanding what you have and what you need will help you submit ‘clean’ claims.

According to Technopedia, data validation checks for the integrity and validity of data and ensures the data complies with the requirements. So, what requirements? Often people assume that this means payer requirements, but that is typically not standard. Validation rules are built into your practice management software and can be used for several points.  Following are some common rules you may find in your program:

  • Ensure NPI‘s and Tax IDs are the appropriate lengths
  • Ensure patients date of birth is entered
  • Ensure that a procedure code and place of service are present on each claim

 

While these scenarios are standard across the industry, there may be other situations that a validation rule can help. Some programs will allow you to create custom rules for your practice. A customized validation rule will allow you to create a rule for a payer requirement.  For instance, you could create a rule to prevent the following:

  • Do you have a code that always requires a modifier, but only for a specific payer?
  • Work with pediatrics and always need the ‘relationship to insured’ to read something other than self
  • How about insurance ID numbers that are a specific alpha-numeric combo, like 3 letters followed by 9 digits?

 

Keep in mind, if you are creating validation rules the program will make sure that the criteria are met based on the rule entered into your software. When creating custom rules, it is important to note that this will not verify payer billing guidelines. You will need to obtain information directly from your payer to create a rule that coincides with their policies.

Once any validation errors have been addressed your claims will go to the clearinghouse you are working with. Most clearinghouses offer claim scrubbing for an additional fee.  Technopedia defines data scrubbing as the procedure of identifying and then modifying or removing incomplete, incorrect, inaccurately formatted, or repeated data.

 

Claim scrubbing is available in several ways. It may be used within your practice management system, your clearinghouse, or even a third-party vendor. Claim scrubbing services can vary greatly in what they are looking for.

Once the claim has left your practice management system it will likely go through at least 2 scrubbing programs—one with the clearinghouse and one with your payer, prior to accepting the claim for processing. When claims are found to have an error, these results are sent back through a Claim Status Report (ANSI 277 file or a human-readable text file). This report will include information about why the claim cannot be processed. This report will also indicate whether it is the clearinghouse or the payer that is rejecting the claim. If you have further questions about the rejection, you will need to contact the entity that has rejected it.

 

Checking the Claim Status Reports on a regular basis will help you correct the errors and resubmit in a timely manner. In addition, the information you have gathered from the rejections can be used to update internal processes or create customized validation rules to prevent future rejections for the same error–saving you time and money!

RCM Insight is a medical billing company that uses EZClaim’s medical billing software. For any details that have to do with claims validation and “scrubbing,” contact RCM Insight directly.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

[ Contribution by Stephanie Cremean’s with RCM Insights ]